Lymphoma

What lymphoma is — in plain words

Your body has a second circulation alongside the blood: the lymphatic system. It carries lymph fluid through hundreds of small filters called lymph nodes, found in the neck, armpits, chest, abdomen and groin. The white cells that live in this system — lymphocytes — defend you against infection. When one of those lymphocytes starts to multiply abnormally, you have lymphoma.

Because lymph nodes are everywhere, lymphoma can show up anywhere — though painless swelling in the neck, armpit or groin is the most common first sign.

Hodgkin vs Non-Hodgkin — the basic split

How lymphoma usually presents

• A painless, rubbery, persistent lump in the neck, armpit or groin — bigger than 1.5 cm and not going away over weeks.
• "B symptoms": unexplained fever, drenching night sweats (the kind that need a change of bedclothes), and unintended weight loss of more than 10% of body weight over six months.
• Itching all over without a rash — classically described in Hodgkin lymphoma.
• Fatigue beyond the usual.
• Shortness of breath or a persistent cough from enlarged nodes in the chest.
• Abdominal fullness, early satiety or back pain from nodes in the abdomen or an enlarged spleen.

Most lumps in the neck are not lymphoma — infections cause far more. But a lump that has been there for more than four weeks, especially without a clear infection, deserves a proper look.

"I tell my young patients with Hodgkin lymphoma the truth: this is a serious illness, the treatment will be hard for a few months, and the great majority of you will be cured. Then we get to work."

How we diagnose lymphoma

The single most important test is a biopsy of an entire lymph node — an excisional biopsy. Needle biopsies sometimes work but often don't give enough tissue or architectural detail to subtype the lymphoma correctly. If you are offered a fine-needle aspirate of a suspicious node, ask whether an excisional biopsy is feasible — it usually is, and it saves a second procedure later.

Alongside the biopsy, the workup includes:

• Immunohistochemistry on the biopsy — paints the cells with markers (CD20, CD30, CD15, others) that identify the subtype.
• Blood tests: CBC, LDH, kidney and liver function, hepatitis B/C and HIV (important before certain treatments), pregnancy test where relevant.
• PET-CT scan from skull base to mid-thigh — now the standard for staging most lymphomas and for assessing response.
• Bone marrow biopsy in selected subtypes (less often needed now that PET-CT is routine).
• Echocardiogram before any anthracycline-based regimen (to confirm the heart is strong enough).

Staging — the Ann Arbor system

Lymphoma is staged I to IV, depending on how many lymph node regions are involved and whether the disease has reached organs outside the lymphatic system.

The letters A or B are added depending on whether B symptoms are present. Importantly, in lymphoma — unlike most cancers — even stage IV disease is often curable.

Treatment — by subtype

Classical Hodgkin Lymphoma

The backbone has long been ABVD (adriamycin, bleomycin, vinblastine, dacarbazine), given every two weeks for two to six cycles depending on stage, sometimes followed by involved-site radiotherapy. Modern variations include BV-AVD (substituting brentuximab vedotin for bleomycin) for advanced disease, and the addition of checkpoint inhibitors (nivolumab, pembrolizumab) for relapsed disease.

Diffuse Large B-Cell Lymphoma (DLBCL)

The standard regimen is R-CHOP — rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone — given every three weeks for six cycles. About two-thirds of patients are cured outright. For those who relapse, options include second-line chemotherapy and, increasingly, CAR-T cell therapy at specialist centres.

Follicular Lymphoma and other indolent lymphomas

Slow-growing lymphomas often do not need immediate treatment. When treatment is needed, options include rituximab alone, rituximab with bendamustine or CHOP, and newer targeted agents. Many patients live with their lymphoma — well — for decades.

Mantle Cell, Burkitt, T-cell lymphomas

These rarer subtypes are treated with specific intensive regimens. The principles are the same: precise subtyping, regimen matched to the disease, response assessed by PET.

What outcomes look like — honestly

Lymphoma is one of the most rewarding areas of oncology because the news is so often good. Classical Hodgkin lymphoma has a cure rate above 80% across all stages. DLBCL is cured in roughly two out of three patients with first-line treatment, and many of the remaining one-third are salvaged with second-line therapy or CAR-T. Even when cure is not the goal — as in many indolent lymphomas — the disease can often be controlled for many years with treatments that fit around normal life.

Daily life during treatment

R-CHOP and ABVD are tiring — there is no point pretending otherwise — but most patients keep working part-time, see family, attend functions between cycles, and return to normal life within a few months of finishing. Hair loss is common with these regimens and grows back. We'll plan around Ramadan, weddings, work deadlines, and travel as best we can.

After treatment — survivorship

Finishing treatment is a milestone. Follow-up visits taper from every few months in the first two years to once a year. Long-term watchpoints — heart health after anthracyclines, second cancers after radiotherapy, fertility, thyroid function — become part of the plan. Read about survivorship care →